Nutrition Prescription


Introduction

 

Patient's Name _______________

Date __________
1: Food Groups
 
Recommended Daily Amounts Daily Amounts You Eat Additional Amounts Needed
Grains (bread, cereal, rice & pasta)
3-6 oz. whole grains    
Vegetables
2 1/2 cup    
Fruits
2 cups    
Dairy 3 cups    
Meat or Meat Alternatives  5-6 1/2 oz.    
2: Fats, Oils & Sweets

Recommended: Use sparingly

Amount you eat: ______________________________
3: Beverages

Recommended: Beverages should provide fluids and nutrients without excessive calories.

Current beverage choices that may be a problem: ______________________________
4: Prescription

Your suggested dietary changes are checked below:

____ Eat more whole-grain breads, cereals, rice and pasta.
____ Eat more vegetables.
____ Eat more fruits.
____ Drink more milk, and eat more yogurt and cheese.
____ Eat more meat, poultry, fish, dry beans, eggs and nuts.
____ Eat more low-fat meats, milk, yogurt and cheese.
____ Eat fewer meats, eggs, nuts and dry beans and less poultry and fish.
____ Eat fewer eggs (no more than 4 whole eggs or yolks per week).
____ Eat fewer fats, oils and sweets.
____ Drink fewer sweetened beverages.
____ Drink less alcohol.
____ Eat less salt and fewer high-sodium foods.
____ Drink no- or low-calorie beverages, such as water, unsweetened tea or diet soda pop.
Other prescriptions:

Physician's Signature _____________________

Date ____________